Integration of Substance Use and Primary Care...Feb 04, 2016  · ACUTE PANCREATITIS . MINOR...

Integration of Substance Use and Primary

Care

STEVEN KIPNIS, MD, FACP, FASAM

CLINICAL ASSOCIATE PROFESSOR OF MEDICINE, ALBANY

MEDICAL COLLEGE

Substance Use Disorder

• The abuse of and dependence on a

drug represents a maladaptive

pattern of drug use characterized by

loss of control and/or preoccupation

with activities involved in obtaining

the drug which significantly interferes

with the normal daily functioning of

the individual.

DOPAMINE AND REWARD

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GABA

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HIPP

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dorsal

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Amphetamine Cocaine Opioids Cannabinoids Phencyclidine

Opioids

Ethanol

Barbiturates

Benzodiazepines

Nicotine

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Substance Use Disorder

In the elderly, it is important to note that

biopsychosocial consequences of drug

dependence can be confused with

frequent problems associated with

aging, such as falls or impaired

cognitive function.

Substance Misuse And Older

Adults:Issues And Concerns

• Many physiological changes occur as

people age, which influence:

• absorption

• metabolizing,

• Retention

• elimination of alcohol and other drugs.

Substance Use And Older Adults:

Issues And Concerns

• These changes increase the likelihood of

older adults having adverse reactions to

alcohol and other drugs when combined, or

of having adverse drug reactions even when

they are prescribed at recommended doses.

Substance Use And Older Adults:

Issues And Concerns

• Tolerance for alcohol

and other medications

decreases with age.

Substance Use And Older Adults:

Issues And Concerns

• The majority of

people over the age of

60 who have been

hospitalized, were

admitted due to

alcohol related

illnesses and trauma.

Most Commonly Prescribed

Inappropriate Medications

• “Inappropriate Prescribing for Elderly Americans in a Large Outpatient Population” Curtis et al, Arch Intern Med Vol 164, August 2004 – 162370 subjects

– 21% filled a prescription for 1 or more medications of concern as defined by the Beers revised list of drugs to be avoided

– 15% filled prescriptions for 2 drugs of concern

– 4% filled prescriptions for 3 or more drugs of concern

– Amitriptyline and doxepin accounted for 23% of all claims of concern

– 51% of claim concerns had the potential for severe adverse effects

Recognizing and Treating SUD

• A bleak picture

– Lack of addiction knowledge

– Lack of resource knowledge or availability for

treatment

– Lack of time

• Numerous screens a primary care physician is

suggested to carry out

– Stigma

– Insurance barriers

11

• Alcohol and other drug using patients often

present with other medical problems.

• These medical conditions are

consequences

– Of both their current and their past high risk

behaviors

– Injection or route of drug use

– Direct toxic effects of illicit drugs or caustic

agents 12

Drugs have global adverse

health effects and body changes:

• Dramatic changes in appetite

• Increased body temperature

• Mood swings

• Fatigue

• Insomnia

• Withdrawal aches and pains

13

14

ALCOHOL

3 Types of Senior Alcohol Users

• “Survivors” or early onset drinkers.

– These individuals are defined as having had

long-term problems with alcohol misuse and

abuse, and thus often experience significant

health problems and are estimated to have a

lifespan abbreviated by between 5 and 15

years due to the negative impact and damaging

health effects of chronic alcohol

overconsumption.

15

3 Types of Senior Alcohol Users

• “Reactors” or late-onset drinkers. – These individuals are thought to begin problematic

drinking later in life, in response to specific traumatic

events such as a death of a loved one, illness, or

loneliness—sometimes secondary to retirement. The

loss of professional identity as one moves into one’s

retirement years may very well be an emotional

trauma that, once again, makes a person who took

pride in their emotional identity—and who mourns its

loss—take refuge in alcohol.

16

3 Types of Senior Alcohol Users

• “Binge Drinkers” or intermittent users.

– These individuals may use alcohol only

occasionally but to excess, which can cause

health problems including falls,

gastrointestinal problems, and negative

interactions with prescribed medications. For

these individuals who over-drink infrequently,

the increased impact of alcohol as the body

ages may come as an unwelcome and

unexpected surprise 17

ALCOHOL METABOLISM

1 BEER = BAC OF .015

3 BEERS = BAC OF .05

21ST BIRTHDAY – 21 SHOTS = ~0.350

*ZERO ORDER METABOLISM

** URINE IS 1.3 X’S CONCENTRATION OF THE BLOOD

ALCOHOL CONCENTRATION

DOSING AND OVERDOSING

BLOOD ALCOHOL CONCENTRATION (BAC)

20 - 99 mg%: LOSS OF MUSCULAR COORDINATION

100 - 199 mg%: NEUROLOGIC IMPAIRMENT,ATAXIA,

PROLONGED REACTION, MENTAL IMPAIRMENT,

INCOORDINATION

200 - 299 mg%: NAUSEA, VOMITING, ATAXIA

300 - 399 mg%: HYPOTHERMIA, DYSARTHRIA, AMNESIA, STUPOR

400 - > mg%: COMA

* BAC GREATER THAN 150 IF NOT SHOWING SIGNS OF INTOXICATION OR ANY TIME BAC IS > 300 EQUALS A DIAGNOSIS OF ALCOHOL DEPENDENCE

20

HEALTHY SURFACE VIEWS SPECT SCAN

TOP DOWN VIEW UNDERSIDE VIEW

21

ALCOHOL

INTOXICATION / SOBER

Alcohol Effects

• Greater than 3 drinks at one time – direct

effect on the heart

• High intake of alcohol can lead to:

– High blood presssure

• From withdrawal

• Without withdrawal

• Arrhythmias – Holiday Heart Syndrome (a. fib)

22

Alcohol Effects

• High intake of alcohol can lead to:

– High triglycerides

– Congestive heart failure

– Increased incidence of heart disease and stroke

23

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Alcohol Effects

• High intake of alcohol can lead to:

– Infections:

• Pneumococcal

• Pseudomonas

• Gram Negatives

– Risky Behaviors

• STD

• Hep C

• HIV

25

26

1 2 3

27

28

MALLORY WEISS TEAR

29

30

31

32

33

34

35

36

ACUTE PANCREATITIS

MINOR WITHDRAWAL

TIME

• 6 - 60 HOURS

SYMPTOMS

• TREMULOUS

• INSOMNIA

• NAUSEA

• ANOREXIA

• ANXIETY

• WEAKNESS

MINOR WITHDRAWAL

SIGNS

• ACTION TREMOR

• INATTENTION

• EASY STARTLE

• PLETHORA

• CONJUNCTIVAL INJECTION

• INCREASED REFLEXES

TREATMENT

• PHARMACOLOGIC SUBSTITUTE

PROGNOSIS

• EXCELLENT

Most Commonly Prescribed

Mood Altering Drugs

• BENZODIAZEPINES

– Ativan, Librium, Serax, Valium, Xanax

– For anxiety, insomnia and alcohol withdrawal

– Physiological dependence can occur even when

taken at therapeutic dosage

– Benzodiazepine use for more than 4 months is

not recommended for older adults

Benzodiazepine Use

11% of population use a benzodiazepine

annually

–80% for < 4 months

– 5 % for 4 - 12 months

– 15% > 12 months

Sedative Withdrawal Symptoms

• Psychological

• Central nervous system

• Gastrointestinal

• Cardiovascular and respiratory system

• Miscellaneous

CNS

Headache

Pain

Parasethesia

Stiffness

Weakness

Tremor

Muscle twitches and fasciculation

Convulsions

Ataxia

Dizziness, lightheadedness

Blurred or double vision

Tinnitus

Speech difficulty

Hypersensitivity to light, sound, taste, smell

Insomnia, nightmares

SEDATIVE/HYPNOTICS

BENZODIAZEPINE WITHDRAWAL

• PERCEPTION CHANGES

• ILLUSIONS

• HALLUCINATIONS

• DEPERSONALIZATION

• SENSORY HYPERACTIVITY ( LIGHTS BRIGHTER, NOISE LOUDER,

ETC.)

44

COCAINE

45

46

PET SCAN

47

“CRACK” LUNG

48

1

2

49

50

Normal pink small intestine

51

52

53

54

METHAMPHETAMINE

55

56 METHAMPHETAMINE

57

METHAMPHETAMINE

58

BURNS

59

OPIATES/HEROIN

• Opiates were the second most commonly

reported primary substance of abuse,

reported most frequently by individuals

aged 50 to 59 (SAMHSA)

60

61

HEROIN

ABUSE

62

LEUKOENCEPHALOPATHY

DUE TO SMOKING HEROIN

63

64

65

66

67

68

69

INJECTED MATERIAL EXTRAVESATED INTO

THE SKIN

70

71

IVDU ABSCESS

72

ARTERIAL INJECTION

73

Overdoses

• Related to dose of opioid used

• Related to tolerance

• Almost all patients continue to receive prescription

opioids after a nonfatal overdose. Discontinuation after

the overdose is associated with lower risk for repeat

overdose

– Larochelle et al, Annals of Internal Medicine 2016)

74

OPIATE WITHDRAWAL - EARLY

• LACRIMATION

• YAWNING

• RHINORRHEA

• SWEATING

SENSE OF ANXIETY AND DOOM,

THOUGH NOT LIFE THREATENING

OPIATE WITHDRAWAL - MIDDLE PHASE

• RESTLESS SLEEP

• DILATED PUPILS

• ANOREXIA

• GOOSEFLESH

• IRRITABILITY

• TREMOR

OPIATE WITHDRAWAL - LATE PHASE

INCREASE IN ALL PREVIOUS SIGNS AND SYMPTOMS

INCREASE IN HEART RATE

INCREASE IN BLOOD PRESSURE

NAUSEA AND VOMITING

DIARRHEA

ABDOMINAL CRAMPS

LABILE MOOD

DEPRESSION

MUSCLE SPASM

WEAKNESS

BONE PAIN

78

MARIJUANA

MEDICINE OR DRUG?

79

80

THC

ABUSE

PHARMACOLOGIC ACTIONS

• PSYCHOMOTOR EFFECTS

– OBJECT DISTANCE DISTORTION

– OBJECT OUTLINES DISTORTED

– INABILITY TO MAKE RAPID JUDGMENT

– SLOWED REACTION TIME

– IMPAIRED TRACKING BEHAVIOR

– SLOWED TIME PERCEPTION

ALL ARE DOSE RELATED

82

83

84

* TOXICITY AND ADVERSE EFFECTS

• REPRODUCTIVE/ENDOCRINE SYSTEM

– ALTERS PITUITARY HORMONES

– DECREASES PROLACTIN

– DECREASES GROWTH HORMONE

– DECREASES LUTEINIZING HORMONE

– GALACCTORHEA

– DECREASE TESTOSTERONE IN MALES

– DECREASE SPERM PRODUCTION

– DECREASE SPERM MOTILITY

86

SYNTHETIC CANNABINOIDS

Tait et al, Clinical Tox Jan 2016

• Severe adverse events of synthetic

cannabinoids – stroke

– seizure,

– myocardial infarction

– rhabdomyolysis,

– acute kidney impairment

– psychosis

– hyperemesis

– death 87

88

CIGARETTES

89

NORMAL LUNG BULLOUS EMPHYSEMA

BULLA

90

BULLOUS EMPHYSEMA

91

92

SMOKELESS TOBACCO

93

94

95

96

97

98

99

100

101

ANABOLIC STEROIDS

102

103

104

105

ANABOLIC STEROIDS

WITHDRAWAL • CRAVING

• FATIGUE

• DEPRESSION

• RESTLESS

• ANOREXIA

• INSOMNIA

• DECREASE IN LIBIDO

• HEADACHES

107

MISCELLANEOUS

* INHALANTS/SOLVENTS

COMMON PROBLEMS

• NERVOUS SYSTEM • OTOTOXICITY - DIMETHYL BENZENE (TOLUENE)

• PERIPHERAL NEUROPATHY - HEXANE (GLUE), KETONES AND TOLUENE

• MULTIPLE SCLEROSIS LIKE SYNDROME - NITROUS OXIDE

• SLOWLY REVERSIBLE TRIGEMINAL NEUROPATHY - TRICHLOROETHYLENE

• VERTICAL NYSTAGMUS

• SLURRED SPEECH

• ATAXIA

• IMPAIRED JUDGMENT

• LACK OF COORDINATION

* INHALANTS/SOLVENTS

COMMON PROBLEMS

• OTHER SYSTEMS

• RENAL

• ACUTE TUBULAR NECROSIS

• CHRONIC RENAL FAILURE

• HEPATIC

• CANCER

• PULMONARY

• PULMONARY HYPERTENSION

• BRONCHOSPASM

• CARDIAC

• “SUDDEN SNIFFING DEATH

• DILATED CARDIOMYOPATHY (TRICHLOROETHYLENE)

• HEMATOLOGIC

• METHHEMOGLOBINEMIA (AMYL NITRITES)

* INHALANTS/SOLVENTS

COMMON PROBLEMS

• MISC.

• LEAD POISONING IN GASOLINE INHALERS

• PIGMENTED HANDS AND FACE IN VOLATILE HYDROCARBON INHALERS

• WEIGHT LOSS

• MUSCLE WEAKNESS

• IMPULSIVE BEHAVIOR

* Mothball Abuse Comes Out of the

Closet

• Users place mothballs, which contain paradichlorobenzene, in a bag and inhale from it for about 10 minutes.

• Some users also chew mothballs. The term "bagging" has been used to describe the habit.

– Mental impairment

– loss of coordination

– scaly skin

– Anemia

– Liver failure

– Kidney failure

• Paradichlorobenzene, also found in air fresheners and insect repellents

• The report appears in the July 27, 2006 issue of the New England Journal of

Medicine

NEW CRAZE THAT CAN KILL

• Involves inhaling compressed air from sprays used for cleaning computer keyboards.

• Just one hit can be fatal because youngsters believe there is no volatile substance involved in what they're using. – dust-off products contain

fluorinated hydrocarbon • Neuro damage

• Pulmonary damage

• Kidney failure

• MI

Medical Conditions Worsened

by Alcohol and Drug Use • CV disease – alcohol, stimulants, tobacco

• HTN – alcohol, stimulants, tobacco

• Hepatitis – alcohol, MJ?

• Lung disease – any smoked substance, alcohol and the

immune system

• Irritable Bowel Disease – alcohol

• DM – alcohol (pancreatitis)

• Endocrine system – alcohol, MJ

• Infections – alcohol, MJ

• Depression – any of the sedatives/stimulants (withdrawal)

113

How and Why to Intervene

• National efforts are underway to integrate

medical care and behavioral health

treatment.

– office-based opioid treatment with

buprenorphine (OBOT-B)

• Infrequently used but increase in patient capacity is

on the horizon.

114

How and Why to Intervene

• National efforts are underway to integrate medical care

and behavioral health treatment.

– At-risk drinking, defined as alcohol use that is

excessive or potentially harmful in combination with

select comorbidities or medications, affects about 10%

of older adults in the United States and is associated

with higher mortality.

• The Project SHARE intervention, which uses

patient and provider educational materials,

physician counseling, and health educator support,

was designed to reduce at-risk drinking among this

vulnerable population. 115

SCREEN FOR SUD

Use a Survey Instrument to Assess Risk

of Opioid Use

How to Intervene

• National efforts are underway to integrate medical care

and behavioral health treatment.

– SBIRT is being adapted in different types of medical care

settings, and the workflow processes are being adapted to ensure

efficient delivery, illustrating the successful integration of

behavioral health and medical care.

– Coordinate mental health and primary care services

– Digital Health

• Computer facilitated 5As (CF-5As) model for smoking cessation (ask,

advice, assess, assist, arrange)

118

Treatment Issues With

Older Adults

• Protracted (Post Acute) Withdrawal

• Sensory Changes That Occur With Aging

• Co-occurring Mental Health Issues

• Co-occurring Medical Problems

• History Of Grief/Loss

• Probable Extensive History Of Caregiving

• Addiction In The Family

• Cultural Considerations

• Elder Abuse

Therapeutic Modalities

For Older Adults

• Motivational counseling

• Cognitive-behavioral therapy

• Reminiscence therapy

• Group therapy

• Education groups

• Special issues groups

• Individual therapy

• Family therapy

Concerns Regarding 12-Step

Meeting Attendance

• Being uncomfortable going out at night

• Being uncomfortable with the language at AA meetings (e.g. swearing, slang)

• Being uncomfortable with the appearance of the place where the meeting is held (e.g. having to walk through a crowd of people smoking outside the entrance to the meeting room)

• Being uncomfortable with some of the issues (such as abuse and same sex relationships, etc.) openly discussed at 12 step meetings

Engaging Older Adults in Tx

• The health care system is a typical entry point for older adults who need treatment.

– If substance abuse is addressed in a medical setting (physician’s office, hospital) that enhances the probability that older adults will make changes and/or accept a treatment referral.

• Family concern is another motivating factor for older adults to enter into treatment.

– They typically do not want to lose relationships with their children, grandchildren or spouse.

Engaging Older Adults in Tx

• If an older person is made aware of the

potential for loss of independence or

functioning by a health care professional,

this is a strong motivator for change; it’s a

quality of life issue.

Impact of an Opioid Prescribing Guideline in the Acute Care

Setting

• A retrospective chart review was performed on records of adult emergency department visits from January 2012 to July 2014 for dental, neck, back, or unspecified chronic pain, and the proportion of patients receiving opioid prescriptions at discharge was compared before and after the guideline. Attending emergency physicians were surveyed on their perceptions regarding the impact of the guideline on prescribing patterns, patient satisfaction, and physician−patient interactions.

• In our sample of 13,187 patient visits, there was a significant (p < 0.001) and sustained decrease in rates of opioid prescriptions for dental, neck, back, or unspecified chronic pain. The rate of opioid prescribing decreased from 52.7% before the guideline to 29.8% immediately after its introduction, and to 33.8% at an interval of 12 to 18 months later.

• del Porto et al, Journal of Emergency Medicine 2015

Prevention Strategies For

Older Adult Substance Abusers

• SAMHSA recommendation: Every person age 60 and older “should be screened for alcohol and prescription drug abuse as part of his or her regular physical examination.”

• Educate older adults about substance misuse and abuse in later years.

• Educate people who regularly interact with older adults about substance misuse and abuse in later years.

• Educate community based outreach people to assist in identification and intervention with at-risk seniors.

Prevention Strategies For

Older Adult Substance Abusers

• Prepare people for the changes that occur

once they are retired.

• Encourage development of satisfying leisure

activities throughout the life span.

• Encourage older adults to become involved

in a support group during difficult life

transitions (e.g., bereavement, diagnosis of

chronic medical condition).

Barriers to Integration, Identification &

Treatment

• Stigma

• Lack of knowledge or skills by professionals

• Resistance by family members to name a problem

• Denial

• Symptoms of abuse mistakenly believed to be signs of aging

Barriers to Integration, Identification &

Treatment

• Transportation

• Financial

• Sensory or mobility changes

• Co-occurring medical problems

• Co-occurring mental health problems